Andrew J. Rosenbaum

Bone grafts, bone substitutes and orthobiologics: The bridge between basic science and clinical advancements in fracture healing

The biology of fracture healing is better understood than ever before, with advancements such as the locking screw leading to more predictable and less eventful osseous healing. However, at times one’s intrinsic biological response, and even concurrent surgical stabilization, is inadequate. In hopes of facilitating osseous union, bone grafts, bone substitutes and orthobiologics are being relied on more than ever before. The osteoinductive, osteoconductive and osteogenic properties of these substrates have been elucidated in the basic science literature and validated in clinical orthopaedic practice. Furthermore, an industry built around these items is more successful and in demand than ever before. This review provides a comprehensive overview of the basic science, clinical utility and economics of bone grafts, bone substitutes and orthobiologics.

Plantar Heel Pain

Plantar heel pain is a common complaint encountered by orthopedic surgeons, internists, and family practitioners. Although it is most often caused by plantar fasciitis, this is a diagnosis of exclusion. Other mechanical, rheumatologic, and neurologic causes must be considered first. The history and physical examination are typically all that is needed to make the proper diagnosis, but diagnostic adjuncts are available to assist the clinician. When plantar fasciitis is diagnosed, conservative modalities must be tried first. Corticosteroid injections and extracorporeal shock-wave therapy may also be used. After 6 months of failed conservative treatments, surgical intervention should be considered.

Subtle injuries to the lisfranc joint.

The tarsometatarsal joint complex is an osseous and capsuloligamentous network that includes the 5 metatarsals, their articulations with the cuneiforms and cuboid, and the Lisfranc ligament, a strong interosseous attachment between the medial cuneiform and second metatarsal. A multitude of injury patterns exist involving the tarsometatarsal joint complex; a Lisfranc injury does not delineate a specific injury, but instead a spectrum of processes involving the tarsometatarsal joint complex.

Review of distal tibial epiphyseal transitional fractures.

The closure of the distal tibial physis occurs over an 18-month period between ages 12 and 15 years. During this time period, children are susceptible to several transitional fractures, so labeled because they are transitioning to skeletal maturity. In the setting of an external rotation force, triplane and Tillaux fractures can occur. These fractures, which present similarly to other Salter-Harris growth plate injuries, do not fit neatly into any 1 classification scheme and are not easily evaluated on plain radiographs. Computed tomography scans are required to optimally assess these fractures and to determine the need for closed vs open treatment. Regardless of which treatment modality is chosen, anatomic reduction is the goal. This article discusses the approach to these unique fractures.

Diabetes mellitus: musculoskeletal manifestations and perioperative considerations for the orthopaedic surgeon.

Diabetes mellitus is a disease of uncontrolled hyperglycemia. Despite a more sophisticated understanding of the pathophysiology of diabetes mellitus and despite pharmacologic advancements that enable better glycemic control, the prevalence of this disease and its devastating sequelae continue to rise. The adverse effects of diabetes on the nervous, vascular, and immune systems render the musculoskeletal system vulnerable to considerable damage. Foot involvement has traditionally been thought of as the most severe and frequently encountered orthopaedic consequence. However, the upper extremity, spine, and muscles are also commonly affected. Orthopaedic surgeons are more involved than ever in the care of patients with diabetes mellitus, and they play a vital role in the multidisciplinary approach used to treat these patients. As a result, surgeons must have a comprehensive understanding of the musculoskeletal manifestations and perioperative considerations of diabetes in order to most effectively care for patients with diabetes mellitus.

Evaluating the Quality, Accuracy, and Readability of Online Resources Pertaining to Hallux Valgus

Background. The Internet is one of the most widely utilized resources for health-related information. Evaluation of the medical literature suggests that the quality and accuracy of these resources are poor and written at inappropriately high reading levels. The purpose of our study was to evaluate the quality, accuracy, and readability of online resources pertaining to hallux valgus. Methods. Two search terms (“hallux valgus” and “bunion”) were entered into Google, Yahoo, and Bing. With the use of scoring criteria specific to hallux valgus, the quality and accuracy of online information related to hallux valgus was evaluated by 3 reviewers. The Flesch–Kincaid score was used to determine readability. Statistical analysis was performed with t tests and significance was determined by P values <.05. Results. Sixty-two unique websites were evaluated. Quality was significantly higher with use of the search term “bunion” as compared to “hallux valgus” (P = .045). Quality and accuracy were significantly higher in resources authored by physicians as compared to nonphysicians (quality, P = .04; accuracy, P < .001) and websites without commercial bias (quality, P = .038; accuracy, P = .011). However, the reading level was significantly more advanced for websites authored by physicians (P = .035). Websites written above an eighth-grade reading level were significantly more accurate than those written at or below an eighth-grade reading level (P = .032). Conclusion. The overall quality of online information related to hallux valgus is poor and written at inappropriate reading levels. Furthermore, the search term used, authorship, and presence of commercial bias influence the value of these materials. It is important for orthopaedic surgeons to become familiar with patient education materials, so that appropriate recommendations can be made regarding valuable resources. Levels of Evidence: Level IV

Dedicated orthopaedic operating rooms: beneficial to patients and providers alike.

Objective: Dedicated orthopaedic operating rooms (DOORs) are increasingly popular solutions to reducing after-hours procedures, physician fatigue, and elective schedule disruptions. Although the benefits to surgeons are well understood, there are comparatively few studies that explore the effects of DOORs on patient care. We compared treatments and outcomes for all consecutive patients with femoral neck fractures, 4 years before and 4 years after implementation of a DOOR-based schedule. Design: Retrospective case–control study. Setting: Level 1 academic trauma center. Patients: A total of 111 consecutive trauma patients undergoing surgical management of isolated OTA group 31-B femoral neck fractures. Intervention: Based on individual patient factors and fracture characteristics, patients were managed with either hemiarthroplasty or open reduction internal fixation (ORIF). Main Outcome Measures: Surgical timing, intervention type, perioperative complications, and postoperative length of stay. Results: Retrospective analysis revealed a significant decrease in after-hour surgery (4 PM–7:30 AM) for all femoral neck fractures (66.7%–19.3%; P < 0.001). No significant differences were found between the rates of arthroplasty versus those of open reduction internal fixation. Patients undergoing surgical treatment for femoral neck fractures after DOOR suffered significantly fewer morbidities, including significantly decreased rates of postoperative intensive care unit admissions, stroke, infections, and myocardial infarction or congestive heart failure exacerbations. We also observed a significant decrease in postoperative mortality (5.6% pre-DOOR vs. 0% post-DOOR; P = 0.04). Patients undergoing hemiarthroplasty experienced a significant shorter hospitalization (14.5 days pre-DOOR vs. 9.9 days post-DOOR; P = 0.04). Conclusions: In our experience, a weekday DOOR is closely associated with improvements in both patient safety and outcomes. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Assessment of orthopaedic literacy in an urban emergency department: pilot results of the literacy in musculoskeletal problems (LiMP) project

Background:Health literacy is considered the single best predictor of an individual’s health status. However, it often is difficult to assess. As such, our group developed the Literacy in Musculoskeletal Problems (LiMP) questionnaire, a musculoskeletal-specific literacy assessment tool. We hypothesized that the degree of inadequate musculoskeletal health literacy would be higher than the rate of inadequate general healthy literacy, as assessed through the Newest Vital Sign (NVS). Methods:Each of the 65 study participants completed a demographic questionnaire, the NVS and the LiMP survey. The NVS and LiMP scores were assessed using contingency table analysis. Categorical outcome variables as a function of demographic parameters also were compared using &khgr;2 tests. Results:More subjects were found to have inadequate musculoskeletal literacy (60%) as compared with general health literacy (48%). Contingency table analysis showed that at LiMP scores of less than 6, the sensitivity and specificity (0.74 and 0.59, respectively) were optimized for predicting limited literacy, as defined by an NVS score of 3 or less. A significantly higher rate of adequate musculoskeletal literacy was observed in Caucasian patients and those who had previously seen a physician for a musculoskeletal complaint. Conclusions:The LiMP’s sensitivity and reliability is in line with prior work on disease and specialty-specific literacy, making it a valid and reliable musculoskeletal literacy assessment instrument. It is only with the ability to identify those lacking the skills crucial to making informed decisions regarding their musculoskeletal health that we can accurately target education campaigns, an approach that will ultimately enhance physician-patient interactions and improve clinical outcomes.

Acute fractures of the tarsal navicular.

The tarsal navicular plays an integral role in hind-foot motion and gait, and is the keystone of the foots medial longitudinal arch. As such, injuries to the navicular can be devastating. Acute avulsion, tuberosity, and body fractures have been described. Fractures of the body result from high-energy trauma and are often seen in conjunction with additional ipsilateral foot injuries. Plain radiographs are the gold standard for diagnosis, with computed tomography helpful in the presence of intra-articular fracture extension. Non-operative treatment is reserved for avulsion injuries and non-displaced body fractures. Open reduction and internal fixation must be performed for all other types, as failure to achieve an anatomic reduction can impede proper locomotion. Complications following operative intervention include pain, stiffness, posttraumatic arthritis, avascular necrosis, nonunion, and hindfoot deformity.

The Cavus Foot

The cavus, or high-arched, foot can present in either childhood or adulthood as a function of muscle imbalance. Neurologic, traumatic, and idiopathic processes have been identified, along with residual clubfoot, as the primary causes of adult cavus foot deformity. A thorough history and physical examination is important and can help identify the underlying cause of deformity. Conservative treatment modalities are always used first, with surgical intervention reserved for refractory cases. The goal of surgery is to correct muscle imbalance, which can be achieved via tendon transfers, corrective osteotomies, and, in the most severe cases, fusion.